Advancing Health Equity: Building on Community-Based Innovation

Bob GardnerPeel Cancer Screening Study: Knowledge

Exchange ForumOctober 20, 2011

Key Messages• health inequities are pervasive and damaging• but these inequities can be addressed through comprehensive

health equity strategy• part of this is focusing policy, programs and resources on health

disadvantaged populations by:• identifying priority populations and key systemic access barriers• planning the most effective mix of services and support to meet priority

populations’ diverse needs• peer health ambassadors is one promising direction that can

address the specific needs and barriers faced by particular populations

• this kind of community-based innovation on the ground is a crucial part of advancing equity

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The Problem to Solve = Health Inequities in Ontario

•there is a clear gradient in health in which people with lower income, education or other indicators of social inequality and exclusion tend to have poorer health + major differences between women and men•the gap between the health of the best off and most disadvantaged can be huge – and damaging+ inequitable access to health care•impact and severity of these inequities can be concentrated in particular populations

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Foundations of Health Disparities Roots Lie in Social Determinants of Health

•clear research consensus that roots of health disparities lie in broader social and economic inequality and exclusion

•impact of inadequate early childhood development, poverty, precarious employment, social exclusion, inadequate housing and decaying social safety nets on health outcomes is well established here and internationally

•we need comprehensive strategy to drive policy action and social change across these determinants

April 13, 2023 | www.wellesleyinstitute.com

Three Cumulative and Inter-Connecting Levels in Which SDoH Shape Health Inequities

1. because of inequitable access to wealth, income, education and other fundamental determinants of health →

2. also because of broader social and economic inequality and exclusion→

3. because of all this, disadvantaged and vulnerable populations have more complex needs, but face systemic barriers within the health and other systems →

1. gradient of health in which more disadvantaged communities have poorer overall health and are at greater risk of many conditions

2. some communities and populations have fewer capacities, resources and resilience to cope with the impact of poor health

3. these disadvantaged and vulnerable communities tend to have inequitable access to services and support they need

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POWER StudyGender and Equity

Health IndicatorFramework

Highlights

1. How better access/care within health system can make a difference to most vulnerable

2. Why we need to take SDoH into account in health service planning and delivery

3. How the structure, resources and resilience of communities mediate the impact of SDoH

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Think Big, But Get Going• challenge = health inequities can seem so overwhelming and their

underlying social determinants so intractable → can be paralyzing→ do need comprehensive social and economic strategy and action to

address the foundations and impact of health inequities

• think big and think strategically, but get going• need to start somewhere:

• even though roots of health disparities lie in far wider social and economic inequality, the health system is still crucial to tackling health disparities

• it’s in the health system that the most disadvantaged in SDoH terms end up sicker and needing care

• in addition, there are systemic disparities in access and quality of healthcare that need to be addressed

• we want to ensure equitable access to high quality care• focus today is on engaging with and providing key preventative services

and support to meet needs of particular populations

Specific Problem to Solve: Inequitable Access to Preventive Health Services

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High-Level: Health Equity Strategy Into Action

1. building health equity into all health care planning and delivery• doesn’t mean all programs are all about equity• but all take equity into account in planning their services and outreach

2. aligning equity with system drivers and priorities – such as chronic disease prevention and management, quality

3. embedding equity in provider organizations’ deliverables, incentives and performance management

4. targeting some resources or programs specifically to addressing disadvantaged populations or key access barriers

• looking for investments and interventions that will have the highest impact on reducing health disparities or enhancing the opportunities for good health of the most vulnerable

• looking to improve the health of most disadvantaged, fastest

5. while investing up-stream in health promotion and addressing the underlying determinants of health

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Drilling Down: Solutions for Particular Populations

• taking social context and living conditions into account are part of good service delivery• health disadvantaged populations have more complex and greater needs for

services and support → continuum of care especially important• also face greater barriers – e.g. availability/cost of transportation, childcare,

language, discrimination → facilitated access is especially important • fewer resources to cope (from supportive social networks, to good food and

being able to afford medication)• providers and programs need to know this to customize and adapt care to population

needs and social contexts:• health promotion and care have to be delivered in languages and cultures of

particular population/community• focus in ECFAA on patient-centred care: → means taking the full range of people’s specific needs into account → more intensive case management, referral planning and post-discharge follow-

up in acute side + targeted efforts to reach populations facing access barriers

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Part of the Solutions:Community-Driven Innovation

public health and many community providers have established ‘peer health ambassadors’ to provide system navigation, outreach and health promotion services to particular communities

Peer Health Ambassadors• Members of the community, from the community• Working with established healthcare providers to improve access and

quality of care for targeted populations• including improving access to preventative screening

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Wellesley Research ProjectPurpose• Survey the range and impact of Peer Health Ambassadors• Assess their potential to meet needs of marginalized

populations• Identify key success conditions and enablers to realize this

potential

Methods• Review of literature• Key informant interviews with 10 Toronto community

organizations currently working with peer-based models

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Findings:Great Potential

• Peer Health Ambassadors are a promising model for improving health equity through eliminating barriers to health care and improving engagement• considerable variation in role, level of expertise and “peerness” • three broad areas -- navigating the system, health promotion, and as

integrated into comprehensive service provision

• Marginalized groups prefer healthcare providers who have personal experience with their problems, who understand their viewpoints, and who share key traits (race, gender, religion, sexuality, cancer, drug use, etc.)

• When community impact is reported, the results are generally very positive

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Findings:Facilitators to Effectiveness and Impact

• Financial compensation• Initial and ongoing training/support/mentoring for peers• Clear roles and division of labour + flexibility to accommodate

dynamic needs of both peers and communities being served• Participation of peers in program or service planning and

development• Rigorous quality assurance at every stage• Program evaluation to improve practices

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Findings: Barriers

• Peer life-stage, ability to adapt their own health and lifestyle to work environment

• Breach of peers’ personal boundaries by clients and co-workers, because of the highly personal nature of this work

• Organizational capacity to support peer needs, service demands and client expectations

• Client preferences for credentialed professionals or specific delivery settings

• Resistance from professionals or institutions to community-based delivery• Unstable funding• Challenges in scaling up

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Realizing the Potential of Peer Health Ambassador Initiatives

• Enlist service users and community in planning and development• Provide ongoing training and support, driven by peer and community needs• Provide financial compensation, even during training• Allow for adaptability and flexibility of training and program to suit the needs of

peer workers and clients• Monitor quality• Market the services using mediums that can reach the target population• Link into coordinated continuum of services and support to communities facing

poorer access• Actively pursue alternative funding sources – beyond rigid project funding from

government sources• Evaluate to understand what ‘works’ – for which particular populations, in what

contexts – and build this learning into continuous improvement

Building on the Potential of Community-Based Innovation and Initiatives

• potential:• huge number of community and front-

line initiatives already addressing equity across province

• + equity focused planning through HEIA or other tools will yield useful information on existing system barriers and the needs of disadvantaged populations

• and we’ll be seeing more and more population-specific program interventions

• but• these initiatives and interventions are not

being rigorously assessed• experience and lessons learned are not

being shared systematically• so potential of promising interventions is

not being realized

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Key Messages• Need comprehensive strategy to address health inequities• Part of this is ensuring equitable access to high-quality care

for all• Part of this is always addressing specific problems facing

specific populations – inequitable access to cancer screening for particular communities

• Peer ambassador type initiatives have shown great potential in being able to reach, support and involve marginalized populations

• these speaking notes and further resources on policy directions to enhance health equity, health reform and the social determinants of health are available on our site at http://wellesleyinstitute.com

• my email is bob@wellesleyinstitute.com• I would be interested in any comments on the

ideas in this presentation and any information or analysis on initiatives or experience that address health equity

Following Up

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Wellesley Roadmap for Action on the Social Determinants of Health

1. look widely for ideas and inspiration from jurisdictions with comprehensive health equity policies, and adapt flexibly to Canadian, provincial and local needs and opportunities;

2. address the fundamental social determinants of health inequality – macro policy is crucial, reducing overall social and economic inequality and enhancing social mobility are the pre-conditions for reducing health disparities over the long-term;

3. develop a coherent overall strategy, but split it into actionable and manageable components that can be moved on;

4. act across silos – inter-sectoral and cross-government collaboration and coordination are vital;

5. set and monitor targets and incentives – cascading through all levels of government and programme action;

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Wellesley Roadmap II6 rigorously evaluate the outcomes and potential of programme initiatives and

investments – to build on successes and scale up what is working; 7 act on equity within the health system:

• making equity a core objective and driver of health system reform – every bit as important as quality and sustainability;

• eliminating unfair and inefficient barriers to access to the care people need;• targeting interventions and enhanced services to the most health

disadvantaged populations;8 invest in those levers and spheres that have the most impact on health

disparities such as:• enhanced primary care for the most under-served or disadvantaged

populations;• integrated health, child development, language, settlement, employment, and

other community-based social services;

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Wellesley Roadmap III9 act locally – through well-focussed regional, local or neighbourhood cross-

sectoral collaborations and integrated initiatives;10 invest up-stream through an equity lens – in health promotion, chronic care

prevention and management, and tackling the roots of health disparities;11 build on the enormous amount of local imagination and innovation going on

among service providers and communities across the country;12 pull all this innovation, experience and learning together into a continually

evolving repertoire of effective programme and policy instruments, and into a coherent and coordinated overall strategy for health equity.

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